Joyce Roberts

A comparison of two bearing-down techniques during the second stage of labor

Abstract This pilot study focuses on the bearing-down phenomenon of the second stage of labor, within the theoretical framework of Levines conservation principles for nursing practice. The purpose of this study is to contrast the effects of two learned approaches to parturient participation during the second stage of labor. A control group (n = 5) was taught the traditional approach to second stage bearing-down efforts: sustained breath-holding. An experimental group (n = 5) was taught to bear-down only with the involuntary urge. No differences were found in the mean duration of the second stage, phases within second stage, Apgar scores, or matemal report of effort. Perineal integrity was preserved in the experimental group. These findings suggest that involuntary bearing-down efforts are accompanied by adequate labor progress and result in less perineal trauma. Further examination of the common practice of encouraging women to bear down strenuously during the second stage, instead of responding to their involuntary urge, is recommended.

A New Understanding of the Second Stage of Labor: Implications for Nursing Care

A reconceptualization of the second stage of labor is proposed, with an early phase of descent and a later phase of active pushing, as the basis for nursing care related to direction or support of expectant mothers bearing-down efforts. This reconceptualization challenges the rules that have accompanied second stage by providing criteria for the obstetric conditions optimal for fetal descent that develop during the initial phase of second stage as the fetal head rotates to an anterior position and descends to at least a 1+ station. The phase of active pushing is accompanied by a decline in fetal pH and should be shortened, not only by assisting the woman with effective bearing-down but also by allowing a longer early phase of second stage and encouraging the woman to push only when the obstetric conditions are optimal.

FACTORS ASSOCIATED WITH PERINEAL OUTCOME DURING CHILDBIRTH

This research used a retrospective, relation-searching design to examine the association between factors related to maternal condition, obstetrical practices, and perineal outcome. The sample included nurse-midwifery clients who delivered term infants in the occiput anterior position within an 18-month period (n = 275). Data were obtained from the clinical records. Chi square analysis was used to examine the association among factors. Those factors found to be significantly associated with perineal outcome during childbirth were parity, analgesia use, anesthesia use, maternal position at delivery, and infant weight. Analgesia and anesthesia use and maternal position were further analyzed, controlling for other variables. The implications of these findings to nurse-midwifery practice and the needs for future research are discussed.

EARLY POSTPARTUM ROOMING‐IN AND MATERNAL ATTACHMENT BEHAVIORS IN A GROUP OF MEDICALLY INDIGENT PRIMIPARAS

Introduction of rooming-in at the study site provided an opportunity to examine the impact of rooming-in on maternal attachment behaviors. Maternal attachment scores for 80 mothers who received rooming-in were compared to 72 mothers who delivered before rooming-in and 35 mothers who requested but did not receive rooming-in. All subjects were medically indigent primiparas with no intrapartum or postpartum complications and term healthy infants. The groups were not significantly different in maternal age, race, or ethnicity. Maternal attachment behaviors were recorded during an infant feeding. Rooming-in mothers had significantly higher maternal attachment scores than both control groups. Rooming-in had an independent effect on maternal attachment after the effects of maternal age, episiotomy or lacerations, epidural anesthesia, infant contact at delivery, and time of feeding observation had been accounted for. Of these prior factors, only maternal age had a significant impact on rooming-in. These results suggest that rooming-in helps primiparas to form early attachments to their babies, and that the impact of rooming-in cannot be explained by the mothers motivation for rooming-in. It is important to provide close contact with the infant during the early postpartum, especially for adolescents who may be at higher than average risk of mothering inadequacies.

Changes in Postpartum Perineal Muscle Function in Women With and Without Episiotomies

This report presents results of a comparison perineal muscle function between antepartum and postpartum measurements in a cohort of women with different perineal conditions after childbirth. Data were obtained by using prospective electromyographic perineometry measurements to objectively determine perineal muscle function before and after delivery in 102 women. In addition, 24 nulliparous, non-pregnant women were studied to determine the effect of pregnancy on perineal muscle function. Pregnancy is associated with a decrease in perineal muscle strength and endurance compared with the postpartum state. The degree to which women improved or did not improve perineal muscle function after birth was related to perineal trauma at delivery. After controlling for parity, maternal age, birthweight, smoking status, and antepartum scores, the order of best to worst performance was cesarean birth, intact perineum, first-degree perineal injury, second- or third-degree perineal injury, and episiotomy. Pre- and post-delivery scores were compared for each woman and analyzed according to perineal outcome. Although all other perineal outcome groups increased muscle function by 6 months postpartum, women with an episiotomy had a mean net loss of perineal muscle performance after birth. These observations do not support the use of episiotomy for the purpose of preserving perineal muscle function.

DELIVERY POSITIONS AND PERINEAL OUTCOME

The data from 847 births from a home birth practice where six different positions were used for delivery permitted the analysis of the effect of maternal position on perineal outcome. The obstetrical log also permitted the identification of other factors that influenced maternal position and perineal outcome. The most frequently used birth position was semisitting, in 83% of the births. The incidence of episiotomy was 7%, and of lacerations, 55%. Factors significantly associated with maternal position were fetal presentation (breech) and birth attendant. Fetal position or presentation, infant weight, parity, and the birth attendant were significantly associated with perineal outcome. The predominant use of the semisitting position may explain why there was no association between maternal position and perineal outcome. The influence of the birth attendant on both these factors suggests the impact of attitudes, skill, or ease in assisting the birth on these aspects of obstetrical practice.

Alternative positions for childbirth--part II: second stage of labor.

While the lithotomy position is used extensively in American obstetrical settings, it has been criticized because of the physiological and anatomical compromises it imposes on the mother and her fetus at the time of birth. This paper reviews the variety of positions that may be considered as alternatives to the lithotomy position. It also considers the nature of the parturients expulsive efforts as an additional factor related to maternal position and influencing the duration of second stage as well as fetal/neonatal and maternal status. As in the first stage of labor, a variety of factors are associated with maternal position in contributing to labor outcome.Abstract While the lithotomy position is used extensively in American obstetrical settings, it has been criticized because of the physiological and anatomical compromises it imposes on the mother and her fetus at the time of birth. This paper reviews the variety of positions that may be considered as alternatives to the lithotomy position. It also considers the nature of the parturienfs expulsive efforts as an additional factor related to maternal position and influencing the duration of second stage as well as fetal/neonatal and maternal status. As in the first stage of labor, a variety of factors are associated with maternal position in contributing to labor outcome.

PHASES OF SECOND STAGE LABOR: Four Descriptive Case Studies

In recent years, the second stage of labor has become an area of interest to a number of observers who have described divisions or phases with behavioral characteristics. Using a descriptive case study design, four normal nulliparous women in spontaneous second stage labor were videotaped from the occurrence of involuntary bearing-down efforts or the recognition of complete cervical dilation until birth. Analysis of these videotapes, the accompanying narrative transcripts, and uterine monitor tracings provided evidence that some behaviors changed over the progression of the second stage. These changes could be divided into three behavioral phases that the nurse/midwife can identify in order to recognize the typical pattern of progression and possible deviations from normal.

EARLY MATERNAL ATTACHMENT BEHAVIORS OF ADOLESCENT AND ADULT MOTHERS

This comparison of observed attachment behaviors of 184 medically indigent, low-risk, inner-city adolescent and adult mothers addresses three critical questions unanswered by current research regarding the maternal attachments behaviors of adolescents. The 69 mothers aged 14 to 17 and the 36 mothers aged 18 to 19 exhibited significantly fewer maternal attachment behaviors during in-hospital infant feedings than a control group of 79 mothers aged 20 to 24. Verbal reports of adolescent and adult mothers were not reliable indicators of actual attachment behaviors. Two-way analyses of variance, statistically controlling for other background factors and amount of infant contact, did not diminish the impact of maternal age. However, rooming-in and educational levels appropriate for age both had additional independent impacts on maternal attachment scores.

ALTERNATIVE POSITIONS FOR CHILDBIRTH—Part I: First Stage of Labor*

A contemporary theme in maternity care is the provision of alternatives for childbirth. This paper focuses on alternative positions during the first stage of labor. The variation in positions used through history are examined. Empirical observations of the influence of positions on labor and various physiological considerations are also discussed. The paper includes recent research findings of the effect of specific positions on labor. Maternal position is viewed as a feature in the conduct of labor that must be considered within the context of a variety of factors influencing both a safe and satisfying labor outcome.